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Predicting prognosis in this older group of patients is complex due
to their highly variable health status, driven by their fundamentally
different prognosis to younger patients. We have published two recent
pieces on this theme, showing that firstly though there was an incremental
reduction in the use of evidence-based therapies for ACS (acute coronary
syndrome) with older age and that better survival was associated with...
Predicting prognosis in this older group of patients is complex due
to their highly variable health status, driven by their fundamentally
different prognosis to younger patients. We have published two recent
pieces on this theme, showing that firstly though there was an incremental
reduction in the use of evidence-based therapies for ACS (acute coronary
syndrome) with older age and that better survival was associated with
intensive management at all ages, this benefit was attenuated the older
the patient.(1) Secondly, higher troponin levels are associated with
increasing risk of mortality, but we found very high mortality rates in
older patients even at the lowest troponin values. There was an
attenuation of the prognostic value of troponins in older age and thus,
the prognostic value of troponins depends on patient age in ACS -
essentially, age is the biggest prognostic marker, and arguably markers we
use in younger patients are not as relevant in older patients.(2) Current
risk scores to guide aggressive management of coronary disease in the
older person perform poorly, over-estimating mortality and ignoring
morbidity, perhaps of more relevance to this age group.(3) In a population
of older adults, adjustment for 27 biological risk factors including co-
morbidity, social status, lifestyle and disease factors, cognition and
frailty substantially reduced the association between chronological age
and 5-year mortality (ages 80-84 years: unadjusted relative risk, 4.1;
adjusted relative risk, 1.7).(4)
As outcomes are influenced by both age and co-morbidity, is the under
-treatment of older people with ACS relative to younger patients thus
'appropriate'? Evidence suggests that risks associated with more intensive
management in older people may be related more to their greater co-
morbidity than age alone(5) and thus chronological age alone may not be
the best measure by which to plan clinical management in older people.
Trials also tend to focus on hard outcomes and also rarely take into
account wider prognostic measures such as disability, repeated
hospitalisation and return to independent living that are more relevant in
older people. Others have also written that sometimes following exacting
clincial guidelines that lead to more treatment may not be in the best
interests of the older patient.(6)
The ideal pathway in the older patient for example with an ACS should
not assume early intervention with revascularisation is the optimum
strategy (as is usually the case in the younger patient) but should be a
more holistic management strategy based upon thorough comprehensive
geriatric assessment. Frailty,(7) functional status, and social aspects of
care in the elderly are rarely included as clinical parameters (read wider
prognostic markers) in decisions pertaining to future care. Furthermore,
outcomes beyond survival need assessing, and ones of particular relevance
to the older patient.
1. Zaman MJ, Stirling S, Shepstone L, Ryding A, Flather M, Bachmann
M, et al. The association between older age and receipt of care and
outcomes in patients with acute coronary syndromes: a cohort study of the
Myocardial Ischaemia National Audit Project (MINAP). European Heart
Journal. 2014 March 18, 2014.
2. Myint PK, Kwok CS, Bachmann MO, Stirling S, Shepstone L, Zaman
MJS. Prognostic value of troponins in acute coronary syndrome depends upon
patient age. Heart. 2014 June 26, 2014.
3. Zingone B, Gatti G, Rauber E, Tiziani P, Dreas L, Pappalardo A, et
al. Early and late outcomes of cardiac surgery in octogenarians. Ann
Thorac Surg. 2009 Jan;87(1):71-8.
4. Fried LP, Kronmal RA, Newman AB, Bild DE, Mittelmark MB, Polak JF,
et al. Risk factors for 5-year mortality in older adults: the
Cardiovascular Health Study. JAMA. 1998 Feb 25;279(8):585-92.
5. Rosengren A, Wallentin L, Simoons M, Gitt AK, Behar S, Battler A,
et al. Age, clinical presentation, and outcome of acute coronary syndromes
in the Euroheart acute coronary syndrome survey. Eur Heart J. 2006
Apr;27(7):789-95.
6. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical
practice guidelines and quality of care for older patients with multiple
comorbid diseases: Implications for pay for performance. JAMA. [doi:
10.1001/jama.294.6.716]. 2005;294(6):716-24.
7. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J,
et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of
Gerontology Series A: Biological Sciences and Medical Sciences. 2001 March
1, 2001;56(3):M146-M57.
Dear editor:
We read with great interest the paper by Bass et al[1] on the mnemonics of cholelithiatis in the november 2013 issue of PMJ. The authors conclude that Family History should be considered as a predictive factor. We would like to share our own experience on this matter.
We collected 173 consecutive patients diagnosed of cholelithiasis, inpatients and ambulatory care patients, during January and February, 2014.
In all c...
Dear editor:
We read with great interest the paper by Bass et al[1] on the mnemonics of cholelithiatis in the november 2013 issue of PMJ. The authors conclude that Family History should be considered as a predictive factor. We would like to share our own experience on this matter.
We collected 173 consecutive patients diagnosed of cholelithiasis, inpatients and ambulatory care patients, during January and February, 2014.
In all cases the diagnosis of biliary stones was established by an abdominal ultrasound or surgical confirmation.
Patients were interviewed on sex, age, parity, family history of cholelitiasis. Skin fair and the body mass index were determined by our team.
Parity was considered positive when there was at least one born child. Fat was considered as such with a BMI of 25 or more. A family history was considered positive if a first degree relative had been diagnosed or had surgery for cholelithiasis.
A total of 173 patients were included; with an age average of 50,16 +- 14 years and 79.8 % female. The frequency of each of the 6 Fs studied are a)Fertility:95.7% ; b)Female: 97.8% ; c)Forty: 75.1% ; d)Fat: 69.9% ; e)Family History: 46.2%, f) Fair: 4%
(*Fertility: only females ; fat: excluded 69 patients with surgical confirmation)
According to our results, fertility, female gender, age above 40 years and an increased BMI were the 4 Fs that best predicted cholelithiasis. In Peru, and particularly in Callao, where predominant skin phototypes are III, IV and V and fair skin is very rarely found, the F of fair, should be disregarded[2]. Therefore, we agree with the authors that Family History should also be considered as a predictive factor.
Conflict of Interest: None declared
REFERENCES
1. Bass G, Gilani SNS,Walsh TN.Validating the 5Fs mnemonic for cholelithiasis: time
to include family history. Postgrad Med J 2013;89:638-641.
2. Ramos C, Ramos M. Conocimientos, actitudes y practicas en fotoproteccion y fototipo cutaneo en asistentes a una campana preventiva del cancer de piel. Callao-Peru. Febrero 2010.Dermatol Peru 2010;20(3):169-173
When Professor Weller and her colleagues speak of members of the team
being "on the same page"(1) no mention is made of the patient(or the
patient's advocate)(2) being also on the identical page. To facilitate the
inclusion of the patient in the team I have proposed the use of an
abbreviated patient-held health record which essentially documents the
problem list and the corresponding drug list, and this should be updated...
When Professor Weller and her colleagues speak of members of the team
being "on the same page"(1) no mention is made of the patient(or the
patient's advocate)(2) being also on the identical page. To facilitate the
inclusion of the patient in the team I have proposed the use of an
abbreviated patient-held health record which essentially documents the
problem list and the corresponding drug list, and this should be updated
each time the patient attends a healthcare facility(3). So as to mitigate
the risk of inadvertent adverse drug interactions, the community
pharmacist, too, needs to be on the same page as the patient. Accordingly,
each time new medication is prescribed, the patient should be advised to
take his abbreviated patient-held record with him so that he can spell out
to the pharmacist what his current medications are(4).
Finally, in recognition of the potential for the hierarchical structure to
generate "disastrous consequences"(1), patient-related correspondence from
secondary care to primary care must include a copy to the patient so that
the patient can compile his own medical file, which he can then carry with
him to complement the abbreviated patient-held record in the event of an
admission(here or overseas) to a hospital other than his usual hospital.
The patient can also refer to that medical file if he wants to correct
factual inaccuracies which sometimes creep into the correspondence. At a
stroke such measures would create a level playing field between the
patient and the healthcare team, thereby mitigating the risk of disastrous
consequences attributable to the hierarchical system.
References
(1)Weller J., Boyd M., Cumin D
Teams, tribes, and patient safety: overcoming the barriers to effective
teamwork in healthcare
Postgrad Med J 2014;90:1490154
(2)Jolobe OMP
Bridging the communication gap between healthcare providers and patients'
advocates
Brit J Hosp Med 2012;73:654
(3)Jolobe OMP
The abbreviated patient-held health record: bridging the communication gap
Brit J Hosp Med 2012;73:234
(4) Jolobe OMP
Can phrmacists help prevent adverse drug ineractions from newly prescribed
drugd
Br J Hosp Med 2009;70:360
I would like to thank the author on a thoughtful reflection on the
"unconscious mind" and would like to comment on its relevance in modern
medicine especially psychiatry and allied fields.
Understandably concepts like the "drive theory" or "defence
mechanisms" do not lend themselves to critical appraisal in "Evidence-
based Medicine" terms easily but that in it should not detract from their
usefulness in every...
I would like to thank the author on a thoughtful reflection on the
"unconscious mind" and would like to comment on its relevance in modern
medicine especially psychiatry and allied fields.
Understandably concepts like the "drive theory" or "defence
mechanisms" do not lend themselves to critical appraisal in "Evidence-
based Medicine" terms easily but that in it should not detract from their
usefulness in everyday clinical practice. "Unconscious mind", "drive
theory" and other classic Freudian concepts belong to the set of
hypotheses whose validity might be difficult to prove, but nevertheless
whose utility is unquestionable. Such concepts provide an extremely useful
conceptual framework for clinicians to make sense of hugely complex and
nuanced human behaviour- both "healthy" and "pathological".
While helpful to all medical specialities, they are especially
relevant to mental health clinicians working with patients who do not
easily fit into established diagnostic categories or have significant
personality dysfunction.
Like with other medical theories, with greater knowledge and
technological advancements they can be suitably modified and refined to
the benefit of our patients. Just like any other hypothesis, Freudian
concept of "Unconscious mind" has its strength and limitations and by its
judicious use in the right context we would maximise its clinical utility.
I feel we as clinicians would be doing us and our patients a dis-
service if we remain totally ignorant about it or rigidly dismiss it
outright for not being easily compatible with classic "Evidence-based
Medicine".
Dear Editor
Our editorial was triggered by a PMJ paper showing that in a study carried
out in the US, 76% of first year doctors exhibited burnout. We quoted
other evidence that burnout may occur surprisingly early in careers and is
not necessarily related to seniority. We know that jobs which require
daily face to face interaction with people who are distressed or
challenging lead to high levels of burnout. Sadly it is th...
Dear Editor
Our editorial was triggered by a PMJ paper showing that in a study carried
out in the US, 76% of first year doctors exhibited burnout. We quoted
other evidence that burnout may occur surprisingly early in careers and is
not necessarily related to seniority. We know that jobs which require
daily face to face interaction with people who are distressed or
challenging lead to high levels of burnout. Sadly it is those who are
most empathetic who become emotionally exhausted most quickly. We also
know that isolation, overwork, lack of sleep and lack of expertise all add
to the risk of burnout. New doctors should not have to cope with all of
those at once. There is evidence from the GMC's annual National Trainee
Survey (and before that the London-wide Point of View Survey) that over
the past 16 years the proportion of new doctors who feel stressed, bullied
or sleep-deprived has steadily reduced. We are not aware of any evidence
suggesting it has got worse, though stresses may well have been
transferred to those higher up the career ladder. Big problem is
dependence on doctors in training to deliver service. Not a problem as
such, but it is when service demands mean working under stress and without
colleagues and supervision. Unsupervised work provides experience but
cannot be considered as training. Working in teams, even if the membership
of the teams changes, mitigates against isolation and provides supervision
for the junior members.
Diana Hamilton-Fairley. Elisabeth Paice
We agree that delirium is serious, and more structured instruments
are needed for providers of multiple specialties to detect delirium in
multiple health care settings. While we have no experience on the I-AGeD
in our emergency departments, we note that caregivers often are not
available at the time of emergency presentation. Also, we find veracity of
caregiver reports highly dependent on relationship and time spent wit...
We agree that delirium is serious, and more structured instruments
are needed for providers of multiple specialties to detect delirium in
multiple health care settings. While we have no experience on the I-AGeD
in our emergency departments, we note that caregivers often are not
available at the time of emergency presentation. Also, we find veracity of
caregiver reports highly dependent on relationship and time spent with the
patient. Ideally, providers should have access to tools that use only
patient-level information in addition to tools that use caregiver
information for diagnosing delirium.
In their interesting study Suffoletto et al [1] examined delirium
recognition by emergency physicians. Trained researchers identified
delirium in 24/259 (9%) of emergency room older patients. Diagnosis was
based on CAM -ICU criteria, Richmond Agitation and Sedation scale and an
interview with the surrogate. By contrast, emergency physicians recognised
delirium in only 8/24 cases and misidenti...
In their interesting study Suffoletto et al [1] examined delirium
recognition by emergency physicians. Trained researchers identified
delirium in 24/259 (9%) of emergency room older patients. Diagnosis was
based on CAM -ICU criteria, Richmond Agitation and Sedation scale and an
interview with the surrogate. By contrast, emergency physicians recognised
delirium in only 8/24 cases and misidentified delirium in seven cases.
Delirium is a serious condition, and it is associated with poor outcome.
Recognition of delirium is important and might improve patient outcomes.
Study findings are in line with previous studies that showed there is room
for improving delirium recognition,
We have looked at this problem recently and developed and validated a
new screening instrument, the Informant Assessment of Geriatric Delirium
scale (I-AGeD) [2]. It is a 10 items caregiver baser questionnaire. The I-
AGeD was validated in elderly patients admitted to a geriatric wards of
two general hospitals. Average age in the construction cohort was 86,4
yr, 51/88 suffered from dementia and delirium was found in 31/88. In two
validation cohorts, sensitivity and specificity ranged from 70-88.9% and
66.7 -100%.
Given the present demographics, the incidence of delirium will rise,
and recognition of delirium may be difficult, especially in patients with
dementia. Training physicians outside the field of geriatrics on this
issue is important. We think that an caregiver based screening instrument
might be an efficient way to improve early and fast recognition of
delirium in geriatric patients.
With kind regards,
JPCM van Campen1, HFM Rhodius Meester1, JFM de Jonghe2
1 Slotervaart hospital, department of geriatric medicine, Amsterdam,
the Netherlands
2 Medical Center Alkmaar, department of geriatric medicine, Alkmaar, the
Netherlands
References
1 Brian Suffoletto, Thomas Miller, Adam Frisch, Clifton Callaway,
Emergency physician recognition of delirium, Postgrad Med J 2013 June,
ahead of Print
2 Rhodius- Meester HFM, van Campen JPCM, Wung W, Meagher DM et al,
Development and validation of the Informant Assessment of Geriatric
Delirium Scale (I-AGeD). Recognition of delirium in geriatric patients.
EGM , 2013; 4(2):73-7
Avoiding burnout in new doctors: sleep, supervision and teams
Elisabeth Paice, Diana Hamilton-Fairley 2013;89:493-494
doi:10.1136/postgradmedj-2013-132214
I applaud Paice and Hamilton-Fairley's call for better work schedules
and supervision, but burnout seems to increase with seniority and probably
reflects more fundamental problems. Achieving even the aims mentioned may
be more difficult than the authors suggest...
Avoiding burnout in new doctors: sleep, supervision and teams
Elisabeth Paice, Diana Hamilton-Fairley 2013;89:493-494
doi:10.1136/postgradmedj-2013-132214
I applaud Paice and Hamilton-Fairley's call for better work schedules
and supervision, but burnout seems to increase with seniority and probably
reflects more fundamental problems. Achieving even the aims mentioned may
be more difficult than the authors suggest.
They note that instant teams function well in the airline industry
but link this statement to a paper which referenced stability as one
defining factor for well-structured teams1. The questionnaire to identify
team membership in that study across all types of hospital employees
didn't ask about (or exclude) stability in the 'well-structured' teams
correlated with weaker stressor-strain relationships. One criterion
defining membership of a well-structured team was 'regular team meetings',
which surely implies at least moderate stability. 'Ensuring that there is
a leader, shared goals, well-defined roles, and mutual respect' are indeed
important but stability is also necessary for most medical teams. Instant
teams might function on airline flights but such teams in Medicine present
serious problems for care of patients as well as for clinical supervision
and appraisal of new doctors.
If it 'really isn't that hard' to avoid damaging work schedules, we
might ask why they are still so common and why Deaneries and other bodies
haven't been able to stop them. One answer is, presumably, that the
profession has progressively lost influence in many Trusts. The experience
of 'hospital-at-night' in many Trusts is very different from the original
concept. Too often, a few doctors (without the other help provided in
exemplar sites) are responsible for large numbers of patients. There is
evidence of unacceptable demands on many medical registrars for whom
effective supervision of newer doctors is not possible2
It's interesting that stress and dissatisfaction appear to be
increasing despite overall reduction in working hours. Preparing new
doctors to cope with clinical reorganisations, NHS instability and
employers' attitudes to medical staff is a significant problem. In truth,
fewer doctors in both hospital and general practice seem to want to work
at night and the NHS doesn't yet know how to cope with that. I wonder if
current levels of burnout and dissatisfaction reflect a deeper malaise for
which we might need a different type of conversation?
References
1. Buttigieg SC, West MA, Dawson JF. Well-structured teams and the
buffering of hospital employees from stress. Health Serv Manage Res
2011;24:203-12.
2. Royal College of Physicians. The medical registrar: Empowering the
unsung heroes of patient care. London: RCP, 2013
The occurrence of coronary occlusion in patients without protocol
positive ST segment elevation(1) might be attributable either to early
catheterisation(2)or to left circumflex artery occlusion(3)(4), the latter
also being significantly(p < 0.001) commoner in non ST segment
elevation(NSTEMI) patients catheterised within 6 hours of arrival in
hospital than in STEMI counterparts also catheterised within that time
frame(...
The occurrence of coronary occlusion in patients without protocol
positive ST segment elevation(1) might be attributable either to early
catheterisation(2)or to left circumflex artery occlusion(3)(4), the latter
also being significantly(p < 0.001) commoner in non ST segment
elevation(NSTEMI) patients catheterised within 6 hours of arrival in
hospital than in STEMI counterparts also catheterised within that time
frame(4). According to one study, there is a "higher rate of thrombotic
coronary occlusion in the first NSTEMI patients with early catheterization
than in those catheterized later"(2). That conclusion was based on an
analysis of 878 patients in whom an evaluation was made of the prevalence
of thrombotic occlusion with in time frames of 0-6 hrs, 7-24 hrs, 25-48
hrs, and 49-96 hrs encompassing time elapsed from admission with chest
pain to angiography. A multivariate logistic regression analysis showed
that the time frame of 0-6 hours was the most significant(p < 0.001)
independent marker of coronary occlusion(with reference to the 48-96 hour
interval)(Odds Ratio 3.01, 95% Confidence Interval: 1.94-4.66; p<
0.001), whereas, for anterior ST depression corresponding data for those
parameters amounted to 2.09, 1.36-3.21, p=0.001, respectively, and, for
inferolateral ST depression, corresponding data amounted to 1.83, 1.08-
3.11, and p=0.025, respectively. Total(ie 100%) thrombotic occlusion was
documented in 55% of 141 patients who fell within the 0-6 hr time frame,
and this represented a significant(p < 0.001) trend in comparison with
other time frames. The left circumflex artery was identified as the
culprit artery(in association with the marginal branch and the
intermediate branch) in 50% of patients who fell within that time
frame(2). Conversely, in a study which exclusively enrolled 27,711
patients with myocardial infarction attributable to left circumflex artery
occlusion, the prevalence of NSTEMI was as high as 33%(3). What is more,
in a study where 93% of 125 patients with suspected NSTEMI had coronary
angiography within 6 hours of arrival in hospital the left circumflex
artery was the culprit artery in 26%(as opposed to its involvement in 11%
of 279 STEMI patients), the difference in prevalence being highly
significant(p < 0.001)(4). Accordingly, the greater the delay in
cardiac catheterisation the greater the likelihood that the opportunity
will be missed to identify thrombotic coronary artery occlusion,
especially in patients with left circumflex artery involvement.
References
(1)Apps A., Malhotra A., Tarkin J et al
High incidence of acute coronary occlusion in patients without protocol
positive ST segment elevation referred to an open access primary
angioplasty programme
Postgraduate Medical Journal 2013;89:376-381
(2)Fugueras J., Barrabes JA., Andres M et al
Angiographic findings at different time intervals from hospital admission
in first non-ST elevation myocardial infarction
International Journal of Cardiologydoi.org/10.1016/j.ijcard.2012.09.168
(3)Stribling WK., Kontos MC., Abbate A et al
Left circumflex occlusion in acute myocardial infarction(from the National
Cardiovascular Data Registry)
Am J Cardiol 2011;108:959-963
(4)Koyama Y., Hansen PS., Hanratty CG., Nelson GIC., Rasmussen HH
Prevalence of coronary occlusion and outcome of an immediate invasive
strategy in suspected acut myocardial infarction with and without ST-
segement elevation
Am J Cardiol 2002;90:579-584
Respected Editor,
The case report by Lai et al. [1] was both interesting and informative. We
agree with the usefulness of CT thorax to differentiate pneumothorax from
giant bulla with double wall sign. Though CT offers the most accurate
diagnostic information, it is difficult to transport unstable patient to a
CT suite which is in a remote area from a resuscitative area or to wait
for a specialized technician to perform it...
Respected Editor,
The case report by Lai et al. [1] was both interesting and informative. We
agree with the usefulness of CT thorax to differentiate pneumothorax from
giant bulla with double wall sign. Though CT offers the most accurate
diagnostic information, it is difficult to transport unstable patient to a
CT suite which is in a remote area from a resuscitative area or to wait
for a specialized technician to perform it and a radiologist to interpret
it. Traditionally, the presence of bullae and their advancement are
recognized by chest radiography. At times, even forced expiratory films
are used to demonstrate the existence of bullae [2]. However, limitation
is difficult to differentiate the hairline shadows produced by avascular
bullae from irregular walls of a cavity or cysts in the lung parenchyma in
an emergency setting and may easily be mistaken for a pneumothorax [3]
sometimes.
In this scenario, the bedside transthoracic ultrasonography has emerged as
a reliable technique to detect and exclude pneumothorax which is now well
accepted by the medical community. The effectiveness of ultrasound in
detection of bullae and differentiate it from pneumothorax [4] is well
documented. The lung sliding may be minimal because there may be little
movement of the visceral pleura that covers the bulla. As there is no free
air in the pleural space, the reverberation artifact that produces the
'comet tail artifacts' may be noticed in bullous disease. However, it is
absent when the lung is collapsed as in pneumothorax and thereby helps to
arrive at the diagnosis [5].
Speedy and precise diagnosis of bullous emphysema from pneumothorax will
assist in treatment, as the management of these two entities varies
significantly. Many times patients presenting to the emergency departments
were in extremis and call for an immediate decision making and delaying
can be life threatening. In an emerging culture of protocol and guidelines
regarding effectiveness of treatment, transthoracic ultrasonography may be
considered in the emergency department to assure the high quality of
health care given to patients.
References:
1. Lai CC, Huang SH, Wu TT, Lin SH. Vanishing lung syndrome mimicking
pneumothorax. Postgrad Med J. 2013.
2. Shah N N, Bhargava R, Ahmed Z, Pandey D K, Shameem M, Bachh A A,
Akhtar S, Dar K A, Mohsina M. Unilateral bullous emphysema of lung. Lung
India 2007;24:30-2.
3. Waseem M, Jones J, Brutus S, Munyak J, Kapoor R, Gernsheimer J.
Giant bulla mimicking pneumothorax. J EmergMed 2005;29:155?-8.
4. Chan SS. Emergency bedside ultrasound to detect pneumothorax. Acad
Emerg Med 2003;10: 91-4.
5. Simon BC, Paolinetti L. Two cases where bedside ultrasound was
able to distinguish pulmonary bleb fzom pneumothorax. J Emerg Med.
2005.29:201-5
Predicting prognosis in this older group of patients is complex due to their highly variable health status, driven by their fundamentally different prognosis to younger patients. We have published two recent pieces on this theme, showing that firstly though there was an incremental reduction in the use of evidence-based therapies for ACS (acute coronary syndrome) with older age and that better survival was associated with...
When Professor Weller and her colleagues speak of members of the team being "on the same page"(1) no mention is made of the patient(or the patient's advocate)(2) being also on the identical page. To facilitate the inclusion of the patient in the team I have proposed the use of an abbreviated patient-held health record which essentially documents the problem list and the corresponding drug list, and this should be updated...
I would like to thank the author on a thoughtful reflection on the "unconscious mind" and would like to comment on its relevance in modern medicine especially psychiatry and allied fields.
Understandably concepts like the "drive theory" or "defence mechanisms" do not lend themselves to critical appraisal in "Evidence- based Medicine" terms easily but that in it should not detract from their usefulness in every...
Dear Editor Our editorial was triggered by a PMJ paper showing that in a study carried out in the US, 76% of first year doctors exhibited burnout. We quoted other evidence that burnout may occur surprisingly early in careers and is not necessarily related to seniority. We know that jobs which require daily face to face interaction with people who are distressed or challenging lead to high levels of burnout. Sadly it is th...
We agree that delirium is serious, and more structured instruments are needed for providers of multiple specialties to detect delirium in multiple health care settings. While we have no experience on the I-AGeD in our emergency departments, we note that caregivers often are not available at the time of emergency presentation. Also, we find veracity of caregiver reports highly dependent on relationship and time spent wit...
Dear Madame, Sir,
In their interesting study Suffoletto et al [1] examined delirium recognition by emergency physicians. Trained researchers identified delirium in 24/259 (9%) of emergency room older patients. Diagnosis was based on CAM -ICU criteria, Richmond Agitation and Sedation scale and an interview with the surrogate. By contrast, emergency physicians recognised delirium in only 8/24 cases and misidenti...
Avoiding burnout in new doctors: sleep, supervision and teams Elisabeth Paice, Diana Hamilton-Fairley 2013;89:493-494 doi:10.1136/postgradmedj-2013-132214
I applaud Paice and Hamilton-Fairley's call for better work schedules and supervision, but burnout seems to increase with seniority and probably reflects more fundamental problems. Achieving even the aims mentioned may be more difficult than the authors suggest...
The occurrence of coronary occlusion in patients without protocol positive ST segment elevation(1) might be attributable either to early catheterisation(2)or to left circumflex artery occlusion(3)(4), the latter also being significantly(p < 0.001) commoner in non ST segment elevation(NSTEMI) patients catheterised within 6 hours of arrival in hospital than in STEMI counterparts also catheterised within that time frame(...
Respected Editor, The case report by Lai et al. [1] was both interesting and informative. We agree with the usefulness of CT thorax to differentiate pneumothorax from giant bulla with double wall sign. Though CT offers the most accurate diagnostic information, it is difficult to transport unstable patient to a CT suite which is in a remote area from a resuscitative area or to wait for a specialized technician to perform it...
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